A prospective comparative study of 2 minimally invasive decompression procedures for lumbar spinal canal stenosis: unilateral laminotomy for bilateral decompression (ULBD) versus muscle-preserving interlaminar decompression (MILD)

Prospective comparative analysis of three types of decompressive surgery for lumbar central stenosis: conventional, full-endoscopic, and biportal endoscopic laminectomy

Conventional open laminectomy has long been considered one of the important surgical options for lumbar central stenosis owing to its positive outcomes. However, newer approaches have emerged as alternatives, including full-endoscopic and biportal endoscopic laminectomy. Therefore, a comparison of the outcomes that are associated with each of these surgical methods is warranted. This prospective multicenter trial, initiated in February 2019, compared the outcomes of three lumbar central stenosis surgical approaches: open laminectomy (OPEN), uniportal endoscopy (UNIPORT), and biportal endoscopy (BIPORT). Among 115 participants from seven centers, one-year follow-ups assessed laboratory, radiological, and clinical outcomes. Despite all groups showing adequate decompression and clinical improvement, the OPEN group exhibited less improvement in Visual analog scale (VAS) for back pain scores (p < 0.05) and significant postoperative increases in most laboratory markers. Furthermore, the OPEN group experienced a significant decrease in multifidus muscle cross-sectional area compared to endoscopic groups (p < 0.001). Each surgical techniques produced similar clinical outcomes and dural space expansion. However, endoscopic surgery was associated with better muscle preservation and better relief of back pain. Endoscopic surgery is a reasonable alternative to conventional laminectomy for treating lumbar central stenosis.This trial was registered on CRIS (Clinical Research Information Service, KCT0004355).

The clinical effect of unilateral decompressive laminectomy plus fusion with unilateral biportal endoscopic technique for single level lumbar spinal stenosis

PURPOSE

This study aimed to compare and analyze the effectiveness of unilateral biportal endoscopic (UBE) decompressive laminectomy plus fusion and microscope-assisted open decompressive laminectomy plus fusion.

METHODS

A total of 143 patients with lumbar spinal stenosis were enrolled in this study between March 2020 and February 2021 with a minimum 2 years follow-up visit to our hospital. Sixty-five patients underwent the unilateral biportal endoscopic technique and were assigned to the UBE group, and the remaining 78 patients with microscope assistant were assigned to the Microscope group. The baseline characteristics, clinical outcomes, and radiological data were retrospectively collected and analyzed, as well as Clinical outcomes, radiological data and complications.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics (P > 0.05). The UBE group was demonstrated to be significantly superior in CRP, drainage, blood loss, treatment cost and Hospital stay than the Microscope group (P < 0.05), whereas a significant longer operation time was observed (P < 0.05). The VAS-B, ODI, and JOA-L scores of the UBE group at 1 year follow-up were significantly greater than those of the Microscope group (P < 0.05). Regarding radiological data, there were no significant differences in the section area of the spinal canal and fusion grade between the two groups (P > 0.05).

CONCLUSION

In view of the satisfactory clinical outcomes of patients and notable decompression at the stenosed segment, UBE is a feasible, minimally invasive technique for single level lumbar canal stenosis.

Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications

BACKGROUND

Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently.

AIM

To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature.

METHODS

On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.

RESULTS

A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%.

CONCLUSION

Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation

BACKGROUND

Unilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure.

METHODS

We outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI).

RESULTS

In our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up.

CONCLUSION

The sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Use of a High-Fidelity Training Simulator for Minimally Invasive Lumbar Decompression Increases Working Knowledge and Technical Skills Among Orthopedic and Neurosurgical Trainees

STUDY DESIGN

Prospective comparative study.

OBJECTIVE

To quantify the educational benefit to surgical trainees of using a high-fidelity simulator to perform minimally invasive (MIS) unilateral laminotomy for bilateral decompression (ULBD) for lumbar stenosis.

METHODS

Twelve orthopedic and neurologic surgery residents performed three MIS ULBD procedures over 2 weeks on a simulator guided by established AO Spine metrics. Video recording of each surgery was rated by three blinded, independent experts using a global rating scale. The learning curve was evaluated with attention to technical skills, skipped steps, occurrence of errors, and timing. A knowledge gap analysis evaluating participants' current vs desired ability was performed after each trial.

RESULTS

From trial 1 to 3, there was a decrease in average procedural time by 31.7 minutes. The cumulative number of skipped steps and surgical errors decreased from 25 to 6 and 24 to 6, respectively. Overall surgical proficiency improved as indicated by video rating of efficiency and smoothness of surgical maneuvers, most notably with knowledge and handling of instruments. The greatest changes were noted in junior rather than senior residents. Average knowledge gap analysis significantly decreased by 30% from the first to last trial (P = .001), signifying trainees performed closer to their desired technical goal.

CONCLUSION

Procedural metrics for minimally invasive ULBD in combination with a realistic surgical simulator can be used to improve the skills and confidence of trainees. Surgical simulation may offer an important educational complement to traditional methods of skill acquisition and should be explored further with other MIS techniques.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Radiological Analysis of Minimally Invasive Microscopic Laminectomy for Lumbar Canal Stenosis with a Focus on Multilevel Stenosis and Spondylolisthesis

OBJECTIVE

We retrospectively compared the radiological and clinical outcomes of two different surgical techniques (lumbar spinous process splitting laminectomy [LSPSL] and unilateral laminotomy for bilateral decompression [ULBD]) to treat lumbar spinal canal stenosis (LCS).

METHODS

We performed a retrospective comparative study of 141 consecutive patients with an average age of 70.8 ± 9.4 years who had undergone LSPSL or ULBD for LCS between April 2015 and April 2019. None of the patients had developed remote fractures of the spinous processes using either technique. These cases were divided into 2 groups: group L, 73 patients who had undergone LSPSL from April 2015 to April 2017; and group U, 68 patients who had undergone ULBD from May 2017 to April 2019. The clinical and radiological outcomes and surgical complications at the 1-year postoperative follow-up period were evaluated.

RESULTS

We found no significant differences in the operative time between the 2 groups. However, group U had had significantly less blood loss than group L. The facet joints were significantly well preserved in group U. We examined the multilevel and spondylolisthesis cases separately and found that both surgical procedures were equally effective and that the visual analog scale scores for back or leg pain and Japanese Orthopaedic Association scores had significantly improved postoperatively in each group. Group U showed better outcomes in terms of LCS recurrence, with 3 patients in the group L requiring repeat surgery.

CONCLUSIONS

We found both ULBD and LSPSL to be safe and effective techniques for LCS, even for patients with spondylolisthesis and multilevel disease. ULBD was superior in terms of recurrence prevention, preservation of the facet joints, and less blood loss.

Ligamentum-preserved/Temporary Preserved Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spondylolisthesis: Technical Note and 2-year Follow-up

STUDY DESIGN

Prospective study.

OBJECTIVE

The aim of this study was to prospectively assess the clinical outcomes of modified minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the treatment of singlesegment lumbar spondylolisthesis.

SUMMARY OF BACKGROUND DATA

MIS-TLIF is a safe and effective procedure in the treatment of lumbar degenerative disease. To avoid durotomy and nerve root injury, we modified the surgical order of MIS-TLIF such that the interbody fusion procedure was performed before the decompression procedure.

METHODS

One hundred thirty-nine patients with single-segment lumbar spondylolisthesis were separated into two groups. Sixty-seven patients underwent modified MIS-TLIF (group A). In group B, 72 patients underwent routine MIS-TLIF. The Japanese Orthopedic Association (JOA) score and the visual analogue scale (VAS) scores for lower back pain (LBP) and leg pain were assessed during the postoperative follow-up, and the lumbar interbody fusion rate was evaluated by CT scanning.

RESULTS

The mean operative time, incision length, average blood loss, and incision pain level were not significantly different (P  > 0.05) between the two groups. No nerve root or dural injuries were observed in group A. In group B, there were two cases of dural injury and three cases of nerve root injury. One patient experienced temporary numbness and weakness on dorsiflexion of the foot, which recovered in 3 months. No differences were identified between the two groups when postoperative JOA scores, back pain, leg pain VAS scores, or the lumbar interbody fusion rate.

CONCLUSION

Both methods are effective in the treatment of lumbar degenerative disease. Modified MIS-TLIF is a safe and effective procedure that can significantly reduce the occurrence of injury to the dura and nerve root during decompression and the interbody fusion procedure.Level of Evidence: 3.

Innovations in Spinal Endoscopy

Innovations in spinal endoscopy technology and technique have broadened their applications during the past 10 years. Smaller outer-diameter working-channel endoscopes have permitted safe usage in the cervical spine for full endoscopic decompressions. Endoscopic fusions have now been widely reported, leveraging compatible instrumentation for disc preparation and expandable interbody grafts. This ultra-minimally invasive technique has also enabled the performance of fusion procedures in awake patients under monitored anesthesia care, affording speedier recovery and treatment options for those unable to undergo general anesthesia. Revision surgery after open or minimally invasive posterior discectomy or instrumentation can now be performed with endoscopic techniques, which often leverage the transforaminal approach to avoid scar tissue and adhesions. These procedures, among other endoscopic surgeries, are now being increasingly performed in ambulatory surgery centers, as safe outcomes, economic benefits to the healthcare system, and patients' desire to recover at home are becoming more apparent. Finally, the standardization of endoscopic terminology, which has long been a confounder to proper communication and education in this field, has recently been addressed by leading experts in a consensus document, which will serve as the foundation for future collaborative advancements.

Effects of the difference between lumbar lordosis in the supine and standing positions on the clinical outcomes of decompression surgery for lumbar spinal stenosis

OBJECTIVE

The authors sought to evaluate the relationship between the difference in lumbar lordosis (DiLL) in the preoperative supine and standing positions and spinal sagittal alignment in patients with lumbar spinal stenosis (LSS) and to determine whether this difference affects the clinical outcome of laminectomy.

METHODS

Sixty patients who underwent single-level unilateral laminectomy for bilateral decompression of LSS were evaluated. Spinopelvic parameters in the supine and standing positions were measured preoperatively and at 3 months and 2 years postoperatively. DiLL between the supine and standing positions was determined as follows: DiLL = supine LL - standing LL. On the basis of this determination patients were then categorized into DiLL(+) and DiLL(-) groups. The relationship between DiLL and preoperative spinopelvic parameters was evaluated using Pearson's correlation coefficient. In addition, clinical outcomes such as visual analog scale (VAS) and Oswestry Disability Index (ODI) scores between the two groups were measured, and their relationship to DiLL was evaluated using two-group comparison and multivariate analysis.

RESULTS

There were 31 patients in the DiLL(+) group and 29 in the DiLL(-) group. DiLL was not associated with supine LL but was strongly correlated with standing LL and pelvic incidence (PI) - LL (PI - LL). In the preoperative spinopelvic alignment, LL and SS in the standing position were significantly smaller in the DiLL(+) group than in the DiLL(-) group, and PI - LL was significantly higher in the DiLL(+) group than in the DiLL(-) group. There was no difference in the clinical outcomes 3 months postoperatively, but low-back pain, especially in the sitting position, was significantly higher in the DiLL(+) group 2 years postoperatively. DiLL was associated with low-back pain in the sitting position, which was likely to persist in the DiLL(+) group postoperatively.

CONCLUSIONS

We evaluated the relationship between DiLL and spinal sagittal alignment and the influence of DiLL on postoperative outcomes in patients with LSS. DiLL was strongly correlated with PI - LL, and in the DiLL(+) group, postoperative low-back pain relapsed. DiLL can be useful as a new spinal alignment evaluation method that supports the conventional spinal sagittal alignment evaluation.

Effect of lumbar laminectomy on spinal sagittal alignment: a systematic review

PURPOSE

Positive spinal sagittal alignment is known to correlate with pain and disability. The association between lumbar spinal stenosis and spinal sagittal alignment is less known, as is the effect of lumbar decompressive surgery on the change in that alignment. The objective was to study the evidence on the effect of lumbar decompressive surgery on sagittal spinopelvic alignment.

METHODS

The Cochrane Controlled Trials Register (CENTRAL), Medline, Embase, Scopus and Web of Science databases were searched in October 2019, unrestricted by date of publication. The study selection was performed by two independent reviewers. The risk of systematic bias was assessed according to the NIH Quality Assessment Tool. The data were extracted using a pre-defined standardized form.

RESULTS

The search resulted in 807 records. Of these, 18 were considered relevant for the qualitative analysis and 15 for the meta-synthesis. The sample size varied from 21 to 89 and the average age was around 70 years. Decompression was mostly performed on one or two levels and the surgical techniques varied widely. The pooled effect sizes were most statistically significant but small. For lumbar lordosis, the effect size was 3.0 (95% CI 2.2 to 3.7) degrees. Respectively, for pelvic tilt and sagittal vertical axis, the effect sizes were - 1.6 (95% CI .2.6 to - 0.5) degrees and - 9.6 (95% CI - 16.0 to - 3.3) mm.

CONCLUSIONS

It appears that decompression may have a small, statistically significant but probably clinically insignificant effect on lumbar lordosis, sagittal vertical axis and pelvic tilt.

Comparison of Clinical Outcomes Following Lumbar Endoscopic Unilateral Laminotomy Bilateral Decompression and Minimally Invasive Transforaminal Lumbar Interbody Fusion for One-Level Lumbar Spinal Stenosis With Degenerative Spondylolisthesis

Introduction: Both lumbar endoscopic unilateral laminotomy bilateral decompression (LE-ULBD) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) have been used to treat one-level lumbar spinal stenosis (LSS) with degenerative spondylolisthesis, while the differences of the clinical outcomes are still uncertain.

Methods: Among 60 consecutive patients included, 24 surgeries were performed by LE-ULBD and 36 surgeries were performed by MI-TLIF. Patient demographics, operation characteristics and complications were recorded. Sagittal parameters, including slip percentage (SP) and slip angle (SA) were compared. The visual analog scale (VAS) score, the Oswestry Disability Index (ODI) score, and Macnab criteria were used to evaluate the clinical outcomes. Follow-up examinations were conducted at 3, 6, 12, and 24 months postoperatively.

Results: The estimated blood loss, time to ambulation and length of hospitalization of the LE-ULBD group were shorter than the MI-TLIF group. Preoperative and final follow-up SP of the LE-ULBD group was of no significant difference, while final follow-up SP of the MI-TLIF group was significantly improved compared with preoperative SP. The postoperative mean VAS and ODI scores decreased significantly in both LE-ULBD group and MI-TLIF group. According to the modified Macnab criteria, the outcomes rated as excellent/good rate were 95.8 and 97.2%, respectively, in both LE-ULBD group and MI-TLIF group. Intraoperative complication rate of the LE-ULBD and the MI-TLIF group were 4.2 and 0%, respectively. One case of intraoperative epineurium injury was observed in the LE-ULBD group. Postoperative complication rate of the LE-ULBD and the MI-TLIF group were 0 and 5.6%, respectively. One case with transient urinary retention and one case with pleural effusion were observed in the MI-TLIF group.

Conclusion: Both LE-ULBD and MI-TLIF are safe and effective to treat one-level LSS with degenerative spondylolisthesis.

Facet-Sparing Decompression of Lumbar Spinal Stenosis: The Minimally Invasive Bilateral Crossover Approach

BACKGROUND AND STUDY OBJECTIVE

 One risk of established decompression techniques for lumbar spinal stenosis is the resection of facet joints, especially if they are steeply configured, promoting destabilization. Minimally invasive bilateral crossover decompression aims to preserve the facet joints and thus stability of the spine. The purpose of this study is to demonstrate the feasibility and early results of this technique.

METHODS

 This retrospective case series includes 10 consecutive patients with lumbar stenosis and steep-angle (<35 degrees) facet joints who were treated with minimally invasive bilateral crossover decompression. Eleven segments were decompressed, most commonly L3/L4 (63.6%), followed by L1/L2 and L2/L3 (18.2% each). The effectiveness of surgical decompression was assessed by self-reporting questionnaires.

RESULTS

 After a follow-up of 10.5 months, the Symptom Severity Scale and Physical Function Scale of the Swiss Spinal Stenosis Questionnaire improved by 0.9 (p < 0.05) and 0.7 points, respectively. The mean Oswestry Disability Index improved from 53.9 to 34.6 (p < 0.05). Local and radiating pain under strain showed statistically significant improvement on the Visual Analog Scale (8.9 vs. 5.0 and 8.4 vs. 4.6, respectively). Maximum walking distance increased from 190 to 1,029 m. Apart from one patient requiring surgical decompression of an adjacent segment, there were no reoperations, neurological deteriorations, or other complications.

CONCLUSION

 The results of this study indicate that minimally invasive bilateral crossover decompression is a promising technique for the treatment of spinal canal stenosis. With its design to spare facet joints, it can potentially reduce the risk of spinal instability, especially in patients with steep facet joints.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Novel electromagnetic-based navigation for percutaneous transforaminal endoscopic lumbar decompression in patients with lumbar spinal stenosis reduces radiation exposure and enhances surgical efficiency compared to fluoroscopy: a randomized controlled trial

BACKGROUND

Percutaneous transforaminal endoscopic lumbar decompression (PTELD) is an emerging surgical alternative for treating lumbar spinal stenosis (LSS). However, the foraminoplasty procedure often requires repeated fluoroscopy, and endoscopy just offers a local view. No studies have focused on decreasing radiation exposure with electromagnetic navigation assistance. This study introduces a novel electromagnetic-based navigation (EMN) endoscopic system for PTELD in patients with LSS and compares the results in navigation and fluoroscopy groups.

METHODS

Eighty-eight patients with LSS were randomized into either a navigation (44 patients) or fluoroscopy group. Duration of surgery, cannula placement time, radiation dose, blood loss, intraoperative pain assessment, and postoperative hospitalization stay were evaluated. The clinical outcomes were evaluated using a visual analogue scale (VAS), the Oswestry Disability Index (ODI), 6-minute walk test, and modified Macnab criteria.

RESULTS

Eighty-five patients were followed-up for at least 12 months. The duration of surgery and cannula placement time were significantly more efficient in the navigation group (P=0.03 and P<0.001). Intraoperative pain assessment showed significantly less pain in the navigation group (P=0.038). The radiation dose was significantly higher in the fluoroscopy group than the navigation group (P<0.001). The VAS scores for back (P<0.001) and leg (P<0.001) pain improved significantly in both groups after surgery, as did the ODI (P<0.001) scores. Improvements in walking ability and Macnab criteria assessments at the 12-month follow-up, assessed subjective by patient assessments did not differ between the two groups.

CONCLUSIONS

The EMN system used in PTELD for patients with LSS compared to fluoroscopy enhances efficiency for foraminoplasty, reduces intraoperative pain and levels of radiation exposure. It results in outcomes comparable with results using fluoroscopy.

Tandem Microscopic Slalom Technique: The Use of 2 Microscopes Simultaneously Performing Unilateral Laminotomy for Bilateral Decompression in Multilevel Lumbar Spinal Stenosis

STUDY DESIGN

Technical note, retrospective case series.

OBJECTIVE

Lumbar stenosis can be effectively treated using tubular unilateral laminotomy for bilateral decompression (ULBD). For multilevel stenosis, a multilevel ULBD through separate, alternating crossover approaches has been described as the "slalom technique." To increase efficacy, we introduced this approach with 2 microscopes simultaneously.

METHODS

We collected data on 13 patients, with multilevel lumbar stenosis, operated at our institution between 2015 and 2016 by the aforementioned technique. We assessed surgical time (ST), estimated blood loss (EBL), complications, and revision surgeries. Furthermore, we provide a stepwise instruction for performing the tandem microscopic slalom technique in a safe and efficient manner.

RESULTS

The mean age of the patients was 68 ± 8 years. The ST per level was 68 ± 19 minutes with an EBL per level of 39 ± 30 mL. We had no intraoperative complications and none of our patients required a revision surgery during a mean follow-up of 12 months.

CONCLUSIONS

We have shown that this technique is feasible and can be performed safely for multisegmental lumbar spinal stenosis with minimal tissue trauma and low EBL. Furthermore, randomized controlled studies with a larger sample size may be necessary to drive any final conclusions.

Biportal endoscopic versus microscopic lumbar decompressive laminectomy in patients with spinal stenosis: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic decompressive laminectomy is a widely performed procedure and shows acceptable clinical outcomes. However, the evidence regarding the advantages of biportal endoscopic surgery is weak, a randomized controlled trial is therefore warranted.

PURPOSE

To compare the clinical efficacies of biportal endoscopic and microscopic decompressive laminectomy in patients with lumbar spinal stenosis.

STUDY DESIGN

Randomized controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with single-level lumbar spinal stenosis who required decompressive laminectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures, visual analog scale (VAS) score for low back and lower extremity radiating pain, Oswestry disability index (ODI), European Quality of Life-5 Dimensions (EQ-5D) score, and painDETECT for neuropathic pain. Surgery-related outcomes including operation time, length of hospital stay, postoperative drainage, and serum creatine phosphokinase were evaluated. Perioperative (<30 days) and late (1-12 months) complications were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic or microscopic decompressive laminectomy. The primary outcome was the ODI score at 12 months after surgery based on a modified intention-to-treat strategy. The secondary outcomes included VAS score for low back and lower extremity radiating pain, ODI scores, EQ-5D score, and painDETECT score. There were no sources of funding and no conflicts of interest associated with this study.

RESULTS

There was no significant difference between groups in the mean ODI score at 12 months after surgery (30 in the microscopy vs. 29 in the biportal endoscopy group, p=.635). There were also no significant differences in low back and lower extremity pain VAS scores, ODI, EQ-5D scores, and painDETECT scores at the 3-, 6-, or 12-month follow-up. Operation time, length of hospital stay, serum creatine phosphokinase, and perioperative complications, such as durotomies and symptomatic hematoma, showed no significant differences between the groups; however, one participant underwent additional revision surgery 9 months after the index surgery in the microscopy group.

CONCLUSIONS

Despite the study design limitation of relatively short duration of follow-up, this trial suggests that biportal endoscopic decompressive laminectomy is an alternative to and offers similar clinical outcomes as microscopic open surgery in patients with symptomatic lumbar spinal stenosis.

Full-endoscopic (bi-portal or uni-portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta-analysis

BACKGROUND

Lumbar stenosis causes pain in the lower lumbar spine and lower extremities and reduces the patient's quality of life and walking ability. Thus, these conditions are common surgical indications for spinal stenosis. Previous reports have shown satisfactory clinical outcomes of the full-endoscopic (FE) and MI technique decompressive laminectomy for lumbar stenosis. However, they still remain controversial.

OBJECTIVE

We conducted a systematic review and meta-analysis to compare the postoperative outcomes between FE (bi-portal or uni-portal) and MI technique decompressive laminectomy for lumbar stenosis.

METHOD

We searched all comparative studies that compared postoperative outcomes (operative time, VAS for back and leg pain, ODI in 3 months and last follow-up) of full-endoscopic (bi-portal or uni-portal) and microscopic technique decompressive laminectomy for lumbar stenosis from the PubMed and Scopus databases up to October 16, 2019.

RESULTS

Nine of 1107 studies (five comparative studies and four RCT) (N = 994 patients) were eligible; all studies were included in pooling of FE and MI decompression. Five and three studies were included in pooling of bi-portal endoscopic, uni-portal endoscopic and MI decompression. All three techniques were compared in one study. Eight, nine, seven, eight, five, seven, eight and nine studies were included in pooling of VAS for back, leg, ODI in 3 months and last follow-up and operative time, respectively. The UMD of VAS for back, leg, ODI in 3 months and last follow-up of FE group was - 0.63 (95% CI - 1.15, - 0.12), - 0.15 (- 0.42, 0.11), - 2.06 (- 3.76, - 0.39), - 0.07 (- 0.22, 0.08), - 0.16 (- 0.29, - 0.03), - 0.20 (- 1.20, 0.81) scores and - 3.00 (- 12.25, 6.25) minutes when compared to MI in lumbar stenosis. In terms of complication, FE was lower risk of 0.62 (0.40, 0.96) times when compared to MI. After subgroup analysis, BESS had significant lower back and leg pain within 3 months when compared to MI group, while uni-portal FE had significant lower leg pain in the last follow-up and complication when compared to MI group. There had no difference in ODI and operative time between two groups.

CONCLUSION

FE had statistically significant lower back pain, lower leg pain and lower risk of having complications when compared to MI decompression in lumbar stenosis, while there is no difference in ODI and operative time between both groups. Comparing to MI, BESS had better early postoperative back pain while uni-portal FE had better leg pain and risk of having complications. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient.

LEVEL OF EVIDENCE

III.

Comparison of bilateral decompression via unilateral laminotomy and conventional laminectomy for single-level degenerative lumbar spinal stenosis regarding low back pain, functional outcome, and quality of life - A Randomized Controlled, Prospective Trial

Background

Conventional posterior open lumbar surgery is associated with considerable trauma to the paraspinal muscles. Severe damage to the paraspinal muscles could cause low back pain (LBP), resulting in poor functional outcomes. Thus, several studies have proposed numerous surgical techniques that can minimize damage to the paraspinal muscles, particularly unilateral laminotomy for bilateral decompression. The purpose of this study is to compare the degree of postoperative LBP, functional outcome, and quality of life of patients between bilateral decompression via unilateral laminotomy (BDUL; group U) and conventional laminectomy (CL; group C).

Methods

Of 87 patients who underwent diagnostic and decompression surgery, 50 patients who met the inclusion and exclusion criteria and were followed up for > 2 years were enrolled. The patients were asked to record their visual analog scale pain score after 6, 12, and 24 months postoperatively. BDUL was used for group U, whereas CL was used for group C. The patients were randomly divided based on one of the two techniques, and they were followed up for over 2 years. Functional outcomes were assessed by the Oswestry Disability Index (ODI), Roland–Morris Disability Questionnaire (RMDQ), and SF-36.

Results

Operation time was significantly shorter in group U than in group C (p = 0.003). At 6, 12, and 24 months, there was no significant difference between the two groups in terms of spine-related pain (all p > 0.05). Functional outcomes using ODI and RMDQ and quality of life using SF-36 were not significantly different between the groups (all p > 0.05).

Conclusions

Regarding single-level decompression for degenerative lumbar spinal stenosis, group U had the advantages of shorter operation time than group C, but not in terms of back pain, functional outcome, and quality of life.

Comparative Analysis between Three Different Lumbar Decompression Techniques (Microscopic, Tubular, and Endoscopic) in Lumbar Canal and Lateral Recess Stenosis: Preliminary Report

PURPOSE

The purpose of our study is to compare the results of spinal decompression using the full-endoscopic interlaminar technique, tubular retractor, and a conventional microsurgical laminotomy technique and evaluate the advantages and clinical feasibility of minimally invasive spinal (MIS) lumbar decompression technique in the lumbar canal and lateral recess stenosis.

METHODS

The authors retrospectively reviewed clinical and radiological data from 270 patients who received microsurgical (group E: 72 patients), tubular (group T: 34 patients), or full-endoscopic decompression surgery (group E: 164 patients) for their lumbar canal and lateral recess stenosis from June 2016 to August 2017. Clinical (VAS, ODI, and Mcnab criteria), radiologic (spinal canal diameter, segmental dynamic angle, and disc height), and surgical outcome parameters (CPK level, Operative time, blood loss, and hospital stay) were evaluated pre- and postoperatively and compared among the three groups by means of statistical analysis. Failed cases and complications were reviewed in all groups.

RESULTS

The mean follow-up period was 6.38 months. The Overall clinical success rate was 89.4%. All groups showed favorable clinical outcome. The clinical and radiologic results were similar in all groups. Regarding surgical outcome, group E showed longer operation time than group M and T (group E: 84.17 minutes/level, group M: 52.22 minutes/level, and group T: 66.12 minutes/level) (p<0.05). However, groups E and T showed minimal surgical invasiveness compared with group M. Groups E and T showed less immediate postoperative back pain (VAS) (group E: 3.13, group M: 4.28, group T: 3.54) (p<0.05), less increase of serum CPK enzyme (group E: 66.38 IU/L, group M: 120 IU/L, and group T: 137.5 IU/L) (p<0.05), and shorter hospital stay (group E: 2.12 days, group M: 4.85 days, and group T: 2.83 days) (p<0.05). The rates of complications and revisions were not significantly different among the three groups.

CONCLUSIONS

MIS decompression technique is clinically feasible and safe to treat the lumbar canal and lateral recess stenosis, and it has many surgical advantages such as less muscle trauma, minimal postoperative back pain, and fast recovery of the patient compared to traditional open microscopic technique.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale

BACKGROUND

Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms.

METHODS

We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement.

RESULTS

Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01).

CONCLUSIONS

ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Minimally invasive decompression in patients with degenerative spondylolisthesis associated with lumbar spinal stenosis. Report of a surgical series and review of the literature

We reported the results of minimally invasive spinal decompression (MISD) in patients with degenerative spondylolisthesis (DS) associated with lumbar spinal stenosis (LSS) and performed a literature review in order to evaluate the clinical and radiological outcomes, the complications and reoperation rate of MISD procedures in these patients. Data of 28 patients submitted to MISD for DS associated to LSS were reviewed. We evaluated the Visual Analogue Scale (VAS) both for low back pain (LBP) and legs pain, the Oswestry Disability Index (ODI) and the degree of the slippage. A PubMed search of the English literature was conducted. Only papers with more than 10 patients and reporting explicitly data of patients with DS were included in the analysis. We found a statistically significant improvement of LBP, legs pain and ODI in our series. The degree of slippage was stable at follow-up (FU) with no need of reoperation. No major complications occurred. In our literature review, we were able to analyze the differences in ODI in 156 patients and the differences in Japanese Orthopedic Association (JOA) score in 218 patients. We observed a statistically significant improvement of ODI and JOA score at FU compared to pre-operative. The percentage of slippage, evaluated in 283 patients, was unchanged at FU compared to pre-operative. The overall complication rate was 1.6%. The overall reoperation rate was 4.5%. MISD procedures are safe and effective in patients with DS associated to LSS and are associated to low morbidity and significant improvement of disability without progression of slippage.

Spinal Cord Stimulation, MILD Procedure, and Regenerative Medicine, Novel Interventional Nonopioid Therapies in Chronic Pain

PURPOSE OF REVIEW

Chronic pain is a highly prevalent condition affecting millions of individuals.

RECENT FINDINGS

In recent years, newer treatments have emerged that are changing the way clinicians treat pain pathogenesis, including novel nonopioid strategies. In this regard, spinal cord stimulation, the MILD procedure, and regenerative medicine have shown promise. This review summarizes recent literature on these three emerging treatment strategies. The results of this review suggest that under certain conditions, spinal cord stimulation, the MILD procedure, and regenerative medicine can be effective treatment modalities.

Percutaneous Endoscopic Laminotomy with Flavectomy by Uniportal, Unilateral Approach for the Lumbar Canal or Lateral Recess Stenosis

OBJECTIVE

To evaluate clinical feasibility and safety of percutaneous endoscopic decompression by a uniportal, unilateral approach for lumbar canal or lateral recess stenosis.

METHODS

In this retrospective study, the procedure was performed with endoscopic instruments in the same way as conventional microscopic laminotomy and flavectomy. Clinical outcomes (visual analog scale, Oswestry Disability Index, modified MacNab criteria) were evaluated. Surgical outcomes, including operative time, hospital stay, and complications, were recorded.

RESULTS

Decompression was performed in 213 patients (232 lumbar levels) for spinal canal or lateral recess stenosis (unilateral laminotomy, n = 80; bilateral laminotomy, n = 152). Mean follow-up period was 26.45 months. Mean visual analog scale for leg pain, and back pain and mean Oswestry Disability Index improved from 8.24%, 5.35%, and 67.8% at baseline to 1.93% (P < 0.001), 2.05% (P < 0.001), and 17.14% (P < 0.001) at final follow-up. Based on modified MacNab criteria, excellent or good results were obtained in 93.8% of patients. Average operative time was 105.3 ± 56 minutes. In the late period of the learning curve, mean operative time was shortened by two thirds, and mean hospital stay was 2.45 days. There were 12 cases of transient postoperative dysesthesia, 3 cases of motor weakness, and 6 cases of dural tear. No patient had postoperative infection, hematoma, or need for revision surgery for incomplete decompression.

CONCLUSIONS

Percutaneous endoscopic decompression by a uniportal, unilateral approach is a safe, clinically feasible, and effective surgical technique for treatment of lumbar stenosis.

Minimally invasive techniques for lumbar decompressions and fusions

PURPOSE OF REVIEW

The purpose of this study is to summarize the recent literature investigating the use of minimally invasive (MIS) techniques in the treatment of lumbar degenerative stenosis, spondylolisthesis, and scoliosis.

RECENT FINDINGS

MIS lumbar decompression and fusion techniques for degenerative pathology are associated with reduced operative morbidity, shortened length of hospital stay, and reduced postoperative pain and narcotics utilization. Recent studies with long-term clinical follow-up have demonstrated equivalence in clinical outcomes between open and MIS surgical procedures. Radiographically, MIS procedures provide adequate postoperative correction of coronal alignment. Correction of sagittal alignment, however, is more variable based on current reports. MIS techniques are both safe and effective in the treatment of lumbar degenerative pathologies. While some studies have reported on long-term outcomes and costs associated with MIS procedures, more investigation into these topics is still necessary. Additionally, further work is required to analyze the training requirements and learning curves of MIS procedures to better promote adoption amongst surgeons.

Changes in HbA1c levels and body mass index after successful decompression surgery in patients with type 2 diabetes mellitus and lumbar spinal stenosis: results of a 2-year follow-up study

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) can hinder a patient's physical activity, which in turn can impair glucose tolerance and body weight regulation in patients with type 2 diabetes mellitus (DM-2). Therefore, successful lumbar surgery could facilitate glycemic control and body weight regulation.

PURPOSE

This study aimed to evaluate the effects of postoperative improvement in physical activity on body mass index (BMI) and hemoglobin A_1c (HbA_1c) level in patients with LSS and DM-2 over a 2-year follow-up period.

STUDY DESIGN

Prospective longitudinal observational study.

PATIENT SAMPLE

Patients with LSS and DM-2.

OUTCOME MEASURES

Visual analogue scale (VAS) scores for back pain and leg pain, Oswestry Disability Index (ODI) scores, Japanese Orthopaedic Association (JOA) scores, JOA Back Pain Evaluation Questionnaire (JOABPEQ) sections, BMI, and blood analysis for HbA_1c were carried out.

METHODS

A total of 119 patients were enrolled for analysis of the effect of successful decompression surgery on changes in HbA_1c levels and BMI. The VAS score, ODI score, JOA score, JOABPEQ, BMI, HbA_1c were reassessed at 6 months, 1 year, and 2 years after surgery. Additionally, correlations between changes in HbA_1c and changes in the ODI, JOA, JOABPEQs, and BMI were analyzed.

RESULTS

The overall values of HbA1c before and at 6 months, 1 year, and 2 years after the surgery were 7.08±0.94%, 6.58±0.87%, 6.59±0.79%, and 6.59±0.79%, respectively (p-values; 6 months: .024; 1 year: .021; 2 years: .038). In the not well-controlled sugar (non-WCS) group (preoperative HbA_1c>6.5%), the difference between pre- and postoperative HbA_1c was highly statistically significant (p<.01). The overweight group (preoperative BMI≥25) showed statistically significant BMI reduction in the second year after surgery (p=.034). The postoperative HbA_1c changes are strongly correlated with the improvements of ODI, JOA, and JOABPEQ after surgery.

CONCLUSIONS

The present study demonstrates that in patients with DM-2 and LSS, successful lumbar surgery may facilitate glycemic control by enabling an increase in the patient's level of physical activity. Additionally, it could help reduce body weight in overweight (BMI>25) patients with DM-2 and LSS.

Lumbar Degenerative Spondylolisthesis: Changes in Surgical Indications and Comparison of Instrumented Fusion With Two Surgical Decompression Procedures

STUDY DESIGN

Single-center retrospective case series.

OBJECTIVE

To compare outcomes of instrumented fusion and two methods of decompression for degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

There is no consensus on the surgical indications or optimum techniques for lumbar degenerative spondylolisthesis.

METHODS

We analyzed the data of 140 patients treated by fusion (n = 80; mean follow-up, 77.9 months) or decompression (n = 60; mean follow-up, 38.0 months) and examined changes in surgical indications over a 12-year period. We compared the outcomes of instrumented fusion with the outcomes of two decompression techniques, the first employing a unilateral approach for bilateral decompression and the second employing a bilateral approach for contralateral decompression, with contralateral foraminal decompression as needed. Postoperative evaluation was made at the final follow-up visit beginning in 2007 by analyzing patient interviews and neurological examination data. We compared results with the Japanese Orthopedic Association symptom score before surgery and at final follow-up.

RESULTS

Surgical indications for fusion narrowed over time, with fusion used less frequently and decompression used more frequently. Similar decreases in clinical symptoms, including low back pain, were achieved with all methods. In the decompression groups, preoperative slip distance and instability, and postoperative slip progression or development of instability, did not correlate significantly with clinical outcome. Slip progression occurred in 8 of 10 levels in patients with preoperative translation ≥5 mm, but these patients showed no increase in instability, defined as translation ≥ 2 mm, at final follow-up.

CONCLUSION

Our findings raise a question about the value of the radiologic criteria for performing fusion used in the late period, namely translation ≥5 mm and/or rotation ≥ 10°. If discogenic pain is excluded, decompression alone may be suitable even for patients with severe low back pain and translation ≥5 mm.

LEVEL OF EVIDENCE

4.

Clinical and Radiological Study Focused on Relief of Low Back Pain After Decompression Surgery in Selected Patients With Lumbar Spinal Stenosis Associated With Grade I Degenerative Spondylolisthesis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of the present study was to identify the clinical and radiological features of low back pain (LBP) that was relieved after decompression alone of lumbar spinal stenosis (LSS) associated with grade I lumbar degenerative spondylolisthesis (LDS).

SUMMARY OF BACKGROUND DATA

Although decompression and fusion are generally the recommended surgical treatments of LDS, several authors have reported that some patients with LDS could obtain good clinical results including relief from LBP by decompression alone. The pathogenesis of relief from LBP after decompression is, however, not known.

METHODS

Forty patients with LSS associated with grade I LDS, who underwent a minimally invasive surgical-decompression were enrolled in the present study. All patients complained preoperatively of predominantly leg-related symptoms and LBP (≥ 4 points on Numeric Rating Scale). Clinical and radiological assessments were performed 1 year after surgery (a relief of LBP: Numeric Rating Scale reduction ≥3 points and valuation ≤3 points) and at the last follow-up. We conducted a comparative study between patient groups with and without the relief from LBP (groups R and N, respectively).

RESULTS

Twenty-nine patients were distributed to group R and the remaining 11 patients to group N. Preoperatively, there was a significant difference between the two groups for age and radiographic flexibility for lumbar extension. Postoperatively, there was a positive correlation between improvement in both LBP and leg symptoms. The clinical outcomes of group R were significantly better than those of group N throughout follow-up period (mean 37 mo). In group R, sagittal lumbopelvic radiographic parameters improved significantly after surgery.

CONCLUSION

Although the causes of LBP are varied in each patients, our results show that concomitant LSS itself might cause LBP in some patients with grade I LDS, because it involves impingement of the neural tissue and discordant sagittal lumbopelvic alignment.

LEVEL OF EVIDENCE

3.

Clinical Outcomes of Spinal Surgery for Patients Undergoing Hemodialysis

This study investigated the surgical outcomes of spinal surgery for degenerative disorder in patients undergoing hemodialysis. Forty patients maintained on hemodialysis who underwent spinal surgery were reviewed. Of the 17 cases of cervical surgery, anterior fusion was performed in 3 patients, laminoplasty in 12, and posterior fusion in 2. Of the 29 cases of lumber surgery, decompression surgery was performed in 14 patients, spinal fusion in 14, and balloon kyphoplasty in 1. The authors focused on cases of destructive spondyloarthropathy (DSA) and retrospectively compared the non-DSA and DSA groups by examining multiple clinical parameters. Intra- or postoperative severe complications occurred in 4 (10%) patients, and 1 (2.5%) patient died due to cardiac failure. The reoperation rate was 27.6% in patients undergoing lumbar surgery and 5.9% in patients undergoing cervical surgery. Five (35.7%) of 14 patients treated with decompression alone subsequently underwent fusion surgery as a revision intervention. Furthermore, 3 (21.4%) of 14 patients undergoing lumbar surgery treated with a primary spinal fusion subsequently underwent an extended fusion surgery. Although there was no significant difference in the recovery rate of the Japanese Orthopaedic Association scores between the non-DSA and DSA groups, severe complications after spinal surgery tended to occur in the DSA group. Although good neurological recovery can be expected in patients undergoing hemodialysis, attention should be paid to the potential for postoperative complications. Severe complications tended to occur in patients with DSA or in those undergoing hemodialysis for more than 15 years. [Orthopedics.2016; 39(5):e863-e868.].

Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: systematic review and current concepts

OBJECT Decompression without fusion for degenerative lumbar stenosis is an effective treatment for both the pain and disability of neurogenic claudication. Iatrogenic instability following decompression may require further intervention to stabilize the spine. The authors review the incidence of postsurgical instability following lumbar decompression, and assess the impact of surgical technique as well as study design on the incidence of instability. METHODS A comprehensive literature search was performed to identify surgical cohorts of patients with degenerative lumbar stenosis, with and without preexisting spondylolisthesis, who were treated with laminectomy or minimally invasive decompression without fusion. Data on patient characteristics, surgical indications and techniques, clinical and radiographic outcomes, and reoperation rates were collected and analyzed. RESULTS A systematic review of 24 studies involving 2496 patients was performed, assessing both open laminectomy and minimally invasive bilateral canal enlargement. Postoperative pain and functional outcomes were similar across the various studies, and postoperative radiographie instability was seen in 5.5% of patients. Instability was seen more frequently in patients with preexisting spondylolisthesis (12.6%) and in those treated with open laminectomy (12%). Reoperation for instability was required in 1.8% of all patients, and was higher for patients with preoperative spondylolisthesis (9.3%) and for those treated with open laminectomy (4.1%). CONCLUSIONS Instability following lumbar decompression is a common occurrence. This is particularly true if decompression alone is selected as a surgical approach in patients with established spondylolisthesis. This complication may occur less commonly with the use of minimally invasive techniques; however, larger prospective cohort studies are necessary to more thoroughly explore these findings.

Clinical and Radiological Comparison between Ipsilateral and Contralateral Side Canal Decompression Using an Unilateral Laminotomy Approach

Objective

To compare the clinical and radiological outcome of both sides using the unilateral approach.

Methods

Unilateral laminotomy was performed to achieve bilateral decompression. Thirty-nine patients who underwent this procedure were analyzed prospectively using the Oswestry Disability Index (ODI), the visual analog scale (VAS) pain score to evaluate symptoms in both legs, and the radiological morphometric index to calculate the anteriorposterior diameter and midcanal width. The incidence of complications from this approach was then evaluated.

Results

The mean follow-up time was 12.2 months. The mean ODI was 48.4 preoperatively and 14.2 postoperatively. The mean dural sac widening of the ipsilateral side (187.0%) was significantly larger (p<0.01) than that of the the contralateral side (145.6%). The VAS improvement ratio ([preoperative VAS score-postoperative VAS score]/[preoperative VAS score]×100) for the pain in each leg was 75.4%(ipsilateral side) and 73.7%(contralateral side). While the VAS improvement ratio for pain in each side was significantly reduced, the difference in the VAS ratio between sides was statistically insignificant (p=0.64). There were 2 cases (5.1%) of dural tearing during the procedure, 1 case (2.6%) of transient paresthesia of nerve roots, and 2 cases (5.1%) of transient paresthesia of the contralateral nerve root. The transient paresthesias of nerve roots never lasted more than 2 weeks.

Conclusion

This technique allows for significant decompression of the contralateral canal and excellent clinical outcomes without troublesome complications. Although ipsilateral the dural sac widening was significantly larger than contralateral side, the difference in the clinical outcome between sides was statistically insignificant.

Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery

INTRODUCTION

The aim of this study was to compare the clinical outcome of spinal process osteotomy with two other midline-retaining methods, bilateral laminotomy and unilateral laminotomy with crossover, among patients undergoing surgery for lumbar spinal stenosis.

METHODS

This cohort study was based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients were operated on between 2009 and 2013 at 31 Norwegian hospitals. The patients completed questionnaires at admission for surgery, and after 3 and 12 months. The Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were duration of surgery and hospital stay, Numeric Rating Scale (NRS) for back pain and leg pain, and EQ-5D and EQ-VAS. The patients were classified into one of three treatment groups according to the surgery they had received, and a propensity score was utilized to minimize bias. The three treatment groups were divided into subgroups based on Propensity Scores, and the statistical analyses were performed with and within the Propensity Score stratified subgroups.

RESULTS

103 patients had spinal process osteotomy, 966 patients had bilateral laminotomy, and 462 patients had unilateral laminotomy with crossover. Baseline clinical scores were similar in the three groups. There were no differences in improvement after 3 and 12 months between treatment groups. At 12 months, mean ODI improvement was 15.2 (SD 16.7) after spinous process osteotomy, 16.9 (SD 17.0) after bilateral laminotomy, and 16.7 (SD 16.9) after unilateral laminotomy with crossover. There were no differences in the secondary clinical outcomes or complication rates. Mean duration of surgery was greatest for spinal process osteotomy (p < 0.05). Length of stay was 2.1 days (SD 2.1) in the bilateral laminotomy group, 3.5 (SD 2.4) days for unilateral laminotomy, and 6.9 days (SD 4.1) for spinous process osteotomy group (p < 0.05).

CONCLUSION

In a propensity scored matched cohort, there were no differences in the clinical outcome 12 months after surgery for lumbar spinal stenosis performed using the three different posterior decompression techniques. Bilateral laminotomy had shortest duration of surgery and shortest length of hospital stay. Surgical technique does not seem to affect clinical outcome after three different midline-retaining posterior decompression techniques.

Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion

BACKGROUND CONTEXT

The Japanese Orthopaedic Association (JOA) scoring system is a physician-based outcome that has been used to evaluate treatment effectiveness after lumbar surgery. However, patient-centered evaluation becomes increasingly important. There is no study that has examined the relationship between the JOA scoring system and patients' self-reported improvement.

PURPOSE

The purpose of the present study was to validate the JOA scoring system for assessment of patient-reported improvement after lumbar surgery.

STUDY DESIGN

This is a retrospective review of prospectively collected data.

PATIENT SAMPLE

The patient sample included 273 mail-in responders of the 466 consecutive patients who underwent posterior lumbar interbody fusion for spondylolisthesis between 1996 and 2008 in a single hospital.

OUTCOME MEASURES

The outcome measures were the JOA scoring system and patients' self-reported improvement.

METHODS

Two hundred seventy three patients were divided into five anchoring groups based on self-reported improvement from "Much better" to "Much worse." Outcomes (ie, recovery rate, amount of change from preoperative condition, and postoperative score) based on the JOA scoring system were compared among groups. Using the patient's self-reported improvement scale as an anchor, the association among each of the outcomes was examined. The cutoff point and the area under the curve (AUC) that differentiated "Improved" from "Neither improved nor worse" was calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

The recovery rate and postoperative score were significantly different in 9 of 10 pairs of anchoring groups. The amount of change was significantly different in six pairs. Spearman correlation coefficient for the 5-point scale anchors of patients' self-reported improvement was 0.20 (p=.001) for the baseline score, 0.31 (p<.001) for the amount of change, 0.55 (p<.001) for the recovery rate, and 0.56 (p<.001) for the postoperative score. According to ROC analysis, the best cutoff points and AUCs were 13 points and 0.69, respectively, for the amount of change, 67% and 0.73, respectively, for recovery rate, and 23 points and 0.72, respectively, for postoperative score.

CONCLUSIONS

The JOA scoring system is a valid method for assessment of patients' self-reported improvement. Patients' self-reported improvement is more likely to be associated with the final condition, such as postoperative score or recovery rate, rather than the change from the preoperative condition.

Unilateral Laminotomy with Bilateral Spinal Canal Decompression for Lumbar Stenosis: A Technical Note

Lumbar stenosis has become one of the most common spinal pathologies and one that results in neurogenic claudication, back and leg pain, and disability. The standard procedure is still an open laminectomy, which involves wide muscle retraction and extensive removal of the posterior spinal structures. This can lead to instability and the need for additional spinal fusion. We present a systemized and detailed approach to unilateral laminotomy for bilateral decompression, which we believe is superior to the standard open laminectomy in terms of intraoperative visualization, postoperative stability, and degree of invasiveness.

Prognostic Factors of Surgical Outcome after Spinous Process-Splitting Laminectomy for Lumbar Spinal Stenosis

STUDY DESIGN

A retrospective case review.

PURPOSE

To assess the clinical and radiographic outcomes and identify the predictive factors associated with poor clinical outcomes after lumbar spinous process-splitting laminectomy (LSPSL) for lumbar spinal stenosis (LSS).

OVERVIEW OF LITERATURE

LSPSL is an effective surgical treatment for LSS. Special care should be taken in patients with degenerative lumbar scoliosis (DLS).

METHODS

A consecutive retrospective case review of patients undergoing LSPSL for LSS with a minimum 2-year follow-up was performed. Mild DLS and mild degenerative spondylolisthesis (DS) were included in the study. The Japanese Orthopedic Association (JOA) score and recovery rate were reviewed. Poor clinical outcome was defined as a recovery rate <50% using Hirabayashi's method.

RESULTS

A total of 52 patients (mean age, 72 years) met the inclusion criteria and had a mean follow-up of 2.6 years (range, 2-4.5 years). The preoperative diagnosis was LSS in 19, DS in 19, and DLS in 14 cases. The mean JOA score significantly increased from 14.6 to 23.2 at the final follow-up. The overall mean recovery rate was 60.1%. Thirteen patients (25%) were assigned to the poor outcome group. A higher rate of pre-existing DLS was observed in the poor outcome (poor) group (good, 15%; poor, 62%; p=0.003) than in the good outcome (good) group. None of the patient factors examined were associated with a poor outcome. A progression of slippage ≥5 mm was found in 8 of 24 patients (33%) in the DS group. A progression of curvature ≥5° was found in 5 of 14 patients (36%) in the DLS group. The progression of scoliosis and slippage did not influence the clinical outcome.

CONCLUSIONS

The clinical and radiographic outcomes of LSPSL for LSS were favorable. Pre-existing DLS was significantly associated with poor clinical outcome.

Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis

PURPOSE

To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or to avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis.

METHODS

A comprehensive electronic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform was conducted for relevant literature up to June 2014.

RESULTS

A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Three different techniques that avoid removal of posterior midline structures are compared to conventional laminectomy; unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy. Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in patients that underwent bilateral laminotomy compared with conventional laminectomy. Unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low. The difference in severity of postoperative low back pain following bilateral laminotomy and split-spinous process laminotomy was significantly less, but was too small to be clinically important. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression.

CONCLUSION

The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies.

Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis

BACKGROUND

The gold standard treatment for symptomatic lumbar stenosis refractory to conservative management is a facet-preserving laminectomy. New techniques of posterior decompression have been developed to preserve spinal integrity and to minimise tissue damage by limiting bony decompression and avoiding removal of the midline structures (i.e. spinous process, vertebral arch and interspinous and supraspinous ligaments).

OBJECTIVES

To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis.

SEARCH METHODS

An experienced librarian conducted a comprehensive electronic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) for relevant literature up to June 2014.

SELECTION CRITERIA

We included prospective controlled studies comparing conventional facet-preserving laminectomy versus a posterior decompressive technique that avoids removal of posterior midline structures or a technique involving only partial resection of the vertebral arch. We excluded studies describing techniques of decompression by means of interspinous process devices or concomitant (instrumented) fusion procedures. Participants included individuals with symptomatic degenerative lumbar stenosis only.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria for randomised controlled trials (RCTs) and the Newcastle-Ottawa Scale for non-randomised studies. We extracted data regarding demographics, intervention details and outcome measures.

MAIN RESULTS

A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Investigators compared three different posterior decompression techniques versus conventional laminectomy. Three studies (173 participants) compared unilateral laminotomy for bilateral decompression versus conventional laminectomy. Four studies (382 participants) compared bilateral laminotomy versus conventional laminectomy (one study included three treatment groups and compared unilateral and bilateral laminotomy vs conventional laminectomy). Finally, four studies (218 participants) compared a split-spinous process laminotomy versus conventional laminectomy.Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in people who underwent bilateral laminotomy compared with conventional laminectomy (two RCTs, 223 participants, odds ratio 5.69, 95% confidence interval (CI) 2.55 to 12.71).Among the secondary outcome measures, unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low (three RCTs, 166 participants, odds ratio 0.28, 95% CI 0.07 to 1.15; three RCTs, 294 participants, odds ratio 0.10, 95% CI 0.02 to 0.55, respectively). The difference in severity of postoperative low back pain following bilateral laminotomy (two RCTs, 223 participants, mean difference -0.51, 95% CI -0.80 to -0.23) and split-spinous process laminotomy compared with conventional laminectomy (two RCTs, 97 participants, mean difference -1.07, 95% CI -2.15 to -0.00) was significantly less, but was too small to be clinically important. A quantitative comparison between unilateral laminotomy and conventional laminectomy was not possible because of different reporting of outcome measures. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression.

AUTHORS' CONCLUSIONS

The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies. Future research is necessary to establish the incidence of iatrogenic instability using standardised definitions of radiological and clinical instability at comparable follow-up intervals. Long-term results with these techniques are currently lacking.